Previable Premature Rupture of Membranes in Dichorionic Diamniotic Twin Gestation, Loss of Leading Twin, Emergency Cervical Cerclage and Ceaserean Delivery at Term ()
1. Introduction
Twin gestations are at an increased risk of premature delivery and may be due to a weakened cervix ( [1] [2] [3]). Preterm birth is a major cause of perinatal mortality and long-term morbidity and multiple gestations account for 20% of preterm births ( [4] [5]). Recurrent premature delivery occurs in 50% - 60% of women with prior premature delivery [6]. However, emergency cerclage placement in multiple gestations has been noted to reduce infant mortality by 77% for patients whose babies had a better chance of surviving preterm birth [3].
There are 2 main approaches in the management of a weakened cervix in pregnancy: Conservative approaches were that you do nothing and application of cerclage, but this latter use is controversial ( [1] [2]). There are three main indications for cervical cerclage: histories of cervical incompetence, recurrent mid-trimester pregnancy loss and preterm premature rupture of fetal membranes prior to 34 weeks [5]. Emergency cerclage in a pre-viable pregnancy at extremely high risk of birth is even more controversial but recent data suggest that multiple pregnancies may fare as well as singleton pregnancies in this situation and that overall benefit is seen ( [4] [7]).
The birth of the first twin is usually followed by the unavoidable delivery of the second twin and in case of immature birth, most fetus dies shortly after delivery [8]. In selected cases, when one fetus is delivered vaginally very prematurely, the remaining fetus can be retained in utero to hope for a delayed-interval delivery which may improve neonatal survival and decrease neonatal morbidity ( [2] [9] [10] [11]). The first report of delaying the delivery of a second twin by 44 days was by Carson [11]. After that first observation, sporadic cases were published, in which a wait-and-see attitude was adopted [10]. However, Thomsen’s paper in 1978 marked the change in the obstetric with the employment of tocolytic, cerclage and prophylactic antibiotics, in twin preterm premature rupture of membrane management [12]. Enakpenes et al. noted that the rate of preterm birth was lower in patients who receive prophylactic antibiotics and tocolytic than in women who did not prior to cerclage insertion [5].
Studies noted that delayed delivery of the second fetus in a twin pregnancy is an effective management choice and the use of cervical cerclage after the first delivery is associated with a longer inter-delivery interval ( [1] [2] [10] [13] [14] [15] [16]). Namouz et al. noted that cerclage insertion did significantly better than bed rest in mean randomization-to-delivery interval, preterm delivery before 34 weeks, and compound neonatal morbidity [17]. It is on this note that we decided to publish this rare case success to add to available knowledge.
2. Case Presentation
Mrs. O.O was a 29 years old G6P1+4 with 1 living child, who is from Igbo tribe but resides at Enugu State Nigeria. She presented to our facility on 27/9/2021 with a last menstrual period of 23/5/2021, expected date of delivery of 30/2/2022 and gestational age of 17 week plus 4 days. An early ultrasound result [Figure 1] done in our facility at gestational age of 6 weeks plus 3 days which she came with showed dichorionic diamniotic gestation. Before then, she was regular with her routine antenatal care and all visits were uneventful. She complained of history of bleeding and drainage of liquor per vaginam of 3 hours duration. It was sudden and unprovoked. There was history of successive 4 previous pregnancies that ended up in complete abortions at 25 weeks, 23 weeks, 20 weeks and 19 weeks respectively in the last 5 years. There was no history of fever, trauma to the abdomen, abnormal vaginal discharge, urinary symptoms or lower abdominal pain. General examination was satisfactory with stable vital signs. Abdominal examination showed an 18 weeks uterine size with no tenderness and no contractions. Pelvic examination with speculum showed liquor in the posterior fornix, no other abnormality noted. There was no active bleeding. Cervix was open
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Figure 1. Ultrasound report prior to the premature rupture of membranes showing twin gestation.
with the leading fetal limbs dangling out of the external cervical os. Delivery of the leading twin and its placenta was done and complete gently. She was admitted into the ward and placed on antibiotics, bed rest and tocolytic while in head down position. Pelvic ultrasound done 24 hours later [Figure 2] showed live singleton fetus with adequate liquor for gestational age, cervical Os was intact, 1.2 cm long, closed with an internal os funneling at 18 weeks gestational age. RVST, HbSAg, HCV and VDRL were negative. Her PCV was 30%, blood group was O Rhesus D+ and Genotype was AA. She was managed as a case of previable premature rupture of membrane on background cervical incompetence and worked up for emergency Cerclage. She subsequently had successful McDonalds Cerclage insertion 3 days later while on admission. Findings were: normal vulva
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Figure 2. Ultrasound report done on admission.
vagina, cervix was 60% effaced and about 1.5 cm dilated, there was mucous discharge covering the cervical os, no traces of blood was seen, the cord, placenta and membranes were not seen and there was no fluid collection in the posterior fornix. She was placed on antibiotics for 4 weeks (intravenous augmentin 1.2 g twice daily for 1 week, then orally for 3 weeks; intravenous metronidazole 500 mg thrice daily for 1 week, then orally for 3 weeks), tablet Drotaverine 80 mg tds for 1 week, tablet Duphaston 10 mg bd for 4 weeks and bed rest in the hospital for 3 days before discharge. In the course of her hospital stay, she was stable, no bleeding and no drainage of liquor and no evidence of pelvic infection prior to discharge. Repeat pelvic ultrasound after 5 weeks [Figure 3] showed live singleton pregnancy with adequate liquor for gestational age; the cervical os was intact
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Figure 3. Ultrasound report done after cervical Cerclage insertion before discharge.
and closed at 23 week gestational age. She continued antenatal clinic 2 weekly till 36 weeks and weekly till 38 weeks. During the antenatal period she was only on routine hematinics and took antenatal prophylaxis. She was booked and subsequently had cervical Cerclage removal and elective caesarean section at 38 weeks on account of cervical incompetence with bad obstetric history at term. Intraoperative findings were: clean peritoneal cavity, well formed lower uterine segment, normally looking tubes and ovaries, a life male neonate weight 3.6 kg and APGAR score of 91, 105, estimated blood loose was 500 mls. She was discharged home on the third day postoperative in good clinical condition. She was seen at 2 weeks and 6 weeks post natal clinic and both baby and mother did well. She subsequently had intrauterine contraceptive device inserted at 6th week post partum and discharged from clinic.
3. Discussion
Our case was a case of dichorionic diamniotic twin gestations that had preterm premature rupture of membrane at 17 weeks with delivery of the leading twin and its placenta. Emergency cerclage was placed to save the second twin; pregnancy was carried to term averting preterm birth and associated morbidities. This collaborated a study that noted that emergency cerclage placement in multiple gestation reduced infant mortality by 77% [3].
Cerclage was placed after stabilization as patient had history of recurrent midtrimester pregnancy loses and preterm premature rupture of fetal membranes. This corresponded to studies that noted emergency cerclage insertion as a management option ( [1] [2]) and histories of recurrent midtrimester pregnancy loses and preterm premature rupture of fetal membranes prior to 34 weeks [5] as indications for preterm premature rupture of membrane with viable cyesis in twin gestation. Emergency cerclage in a pre-viable pregnancy is even more controversial but recent data suggest, that multiple pregnancies may fare as well as singleton pregnancies in this situation and that overall benefit is seen ( [4] [7]). This was evident as our case recorded a significant success.
The birth of the first twin is usually followed by the unavoidable delivery of the second twin [8], however in our case, the use of cerclage saved the second twin. In selected cases, when one fetus is delivered vaginally very prematurely, the remaining fetus can be retained in utero to hope for a delayed-interval delivery which may improve neonatal survival and decrease neonatal morbidity ( [2] [9] [10]). We delayed delivery of the second twin that lead to its survival without any morbidity. Several studies recorded success with use of tocolytic, cerclage and prophylactic antibiotics ( [1] [2] [5] [10] [12] [13] [14] [15] [16]) as was observed in our index case leading to the success we are reporting. Namouz et al. noted that cerclage insertion did significantly better than bed-rest in mean randomization-to-delivery interval, preterm delivery before 34 weeks, and compound neonatal morbidity [17]. It was on these bases that our patient was discharged home after stabilization and cerclage insertion and we had good success without strict bed after discharge.
4. Conclusion
Emergency cervical cerclage should be part of the options of management after stabilization in cases of previable premature rupture of membrane in a dichorionic or multichoronic gestation so as to save the viable twin.
Consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editor-in-chief of this journal.